Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Canyon Oaks Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Dumpster Area Not Kept Free of Spillage Surveyors observed dry, black sticky substance on the ground around both dumpsters, and the left dumpster had black substance dripping from it. The DS could not identify the source of the stains, and the DOM stated the dumpster area should be clean and without spillage. He also stated spills can attract insects, cockroaches, and rats that could enter the facility and potentially cause or spread infection to residents. Facility sanitation policy required garbage and refuse containers to be in good condition, without leaks, and disposal areas to be maintained to prevent pests.
A resident with a seizure history was observed in bed without padded upper siderails despite a seizure prophylaxis order. In another room, an LVN found open A&D ointment packets and an unlabeled cup with white paste left at the bedside, and the DON said the items were inappropriate and should have been disposed of after use. A third resident with dementia and a physician order for bilateral landing mats was observed in bed without the mats in place, and staff interviews showed the order was not consistently followed.
An LVN gave a resident a multivitamin with minerals even though the MAR ordered a multivitamin without minerals, and the resident was observed swallowing the wrong tablet with Boost. The DON and LVN both identified this as a medication error. The facility also had two eKits containing controlled meds without shift-by-shift reconciliation logs and one open emergency eKit that had not been replaced after use within the required timeframe.
Medication Room Station 4 had a medication refrigerator that contained resident meds along with orange juice and apple juice, and an LPN confirmed food should not be stored with meds because of cross contamination. In another finding, a resident who could make own decisions had an unlabeled box of Neosporin left on a tray table at the bedside and stated she used it herself as needed. The DON stated the ointment should have been labeled with the resident’s name and other required information and should not have been left unlabeled at the bedside.
Food storage and tray line monitoring were not handled in accordance with policy. Produce, prepared juice, and other refrigerated items were observed with incorrect or expired dates, and cutting boards were found scratched and grooved. On the tray line, staff did not initially check all hot and cold items, and the temperature log had blank entries and delayed documentation, despite the DS and DON stating temperatures should be checked and recorded at the time of service.
No designated refrigerator was available for residents’ food brought in from outside sources. The DON, RD, ADM, and DS all confirmed the facility did not store outside food, with staff citing liability, monitoring, space, and added temperature-check steps; the DS also stated corporate stopped holding resident food after Covid-19, although the facility previously had a refrigerator for this purpose. Residents and a family member stated they wanted their outside food stored, and the facility policy required labeled storage for food left with residents while stating perishable foods could not be stored and had to be consumed within 2 hours.
Failure to Assess Safe Self-Administration of Bedside Medication: A resident with a history of heart disease, chronic pain, and anxiety had Neosporin kept at the bedside and used it for sores, but the IDT did not complete the required Self-Administration Safety Screen. The DON confirmed no assessment was in the record, and the resident could not clearly explain how often or where the ointment was applied; the TAR documented the bedside order across shifts.
A facility failed to keep call lights within reach for two residents. One resident with COPD, acute respiratory failure with hypoxia, and severe cognitive impairment had the call light on the floor beside the bed after a CNA did not use the clip to secure it. Another resident with hemiplegia/hemiparesis after CVA, type 2 DM, PVD, and moderately impaired cognition had the call light dangling from the bed rail and stated he did not know where it was. The DON stated call lights should always be accessible, and the facility policy required call light access while in bed and in other care areas.
Resident room temperature was found below the facility’s comfortable range in a shared room occupied by two residents. One resident had dementia, severe cognitive impairment, and dependence for most ADLs, while the other had acute and chronic respiratory failure, was cognitively intact, and required substantial assistance. The resident and a family member reported the room was too cold, especially at night, and the DOM measured the room at 70 degrees Fahrenheit, with another nearby room at 68 degrees Fahrenheit. The DON stated the facility should maintain a comfortable temperature to support a homelike environment, and the facility policy called for a safe, comfortable temperature of 71 to 81 degrees Fahrenheit.
CPR Certification Lacked Required Hands-On Training: The facility failed to ensure an LVN maintained a current CPR certification from a provider that included hands-on practice and skills assessment. The LVN stated her CPR course was completed online with videos and a test and did not include an in-person hands-on component. The DON stated CPR training should include hands-on practice, and the facility policy required CPR certification through a provider meeting accepted national standards.
Failure to Float Heels and Use Heel Protectors as Ordered: A resident with DM, falls, and dysphagia had a physician order to float both heels in bed with heel protectors and/or a wedge to offload pressure, but during observation only one heel had a protector and neither foot was floated. An LVN confirmed the order required both heels to be floated, and the DON stated the resident’s heels must be floated and protected at all times while in bed.
A resident with UTI, bacteremia, and dementia had an IV site on the left AC covered with white tape, including the insertion site and date label. An RN stated the site could not be fully monitored for complications because it was not visible and the insertion date could not be verified, and the DON stated the IV site must remain visible for monitoring.
Undated nebulizer and tubing were observed for a resident receiving PRN nebulizer treatment for SOB. RN stated the device and tubing must be labeled with the date and time changed to track when they are due for replacement and to prevent bacteria growth and cross contamination. The DON confirmed the nebulizer should have had a date label, and the facility policy required tubing to be changed every 7 days with the date and time documented.
A resident with dementia, respiratory failure, and impaired decision-making had bilateral quarter rails ordered and installed for mobility and transfers, but the record did not show informed consent was obtained. The care plan called for education and informed consent from the resident or representative, yet the form only showed education, and the ADON and DON confirmed there was no other documentation of consent from the resident’s family representative.
Surveyors found that three cognitively intact residents with diagnoses such as DM, atherosclerosis, fractures, and mixed incontinence were always incontinent of bowel and bladder and required significant assistance with toileting-related ADLs, yet their care plans did not specify the type of bowel and bladder (B&B) retraining program to be used. B&B assessments had identified each as a candidate for Prompted Voiding, Habit Training/Scheduled Voiding, or Bladder Retraining, and care plans included general goals to reduce incontinence episodes, but lacked clear identification of the chosen program and individualized approaches or interventions describing how it would be implemented. During interviews, an MDS nurse and the ADON confirmed that individualized, person-centered B&B retraining care plans had not been developed or implemented for these residents, despite facility policy requiring comprehensive, person-centered care plans based on ongoing assessments.
Three cognitively intact residents with diagnoses including DM, atherosclerosis, fractures, and mixed incontinence were assessed as always incontinent of bowel and bladder and identified as candidates for a Prompted Voiding Program, Habit Training/Scheduled Voiding, or Bladder Retraining. Their MDS assessments showed they required moderate to maximal assistance with toileting-related ADLs and were dependent for toilet transfers. Although each resident’s care plan noted incontinence and set goals to decrease episodes, none of the plans specified which bowel/bladder retraining program would be implemented or detailed individualized interventions. Interviews with an MDS nurse and the ADON confirmed there was no documentation that any toileting or retraining program had been initiated, nor that the residents had been offered, agreed to, or declined participation, despite facility P&P requiring appropriate continence services, scheduled toileting or prompted voiding as appropriate, and documentation of toileting trials in the medical record.
A resident with diabetes and severe cognitive impairment did not receive their prescribed insulin glargine at bedtime, despite their blood sugar being within the ordered parameters. Nursing staff confirmed the omission was due to not fully reading the physician's order, resulting in a failure to provide care in accordance with professional standards and facility policy.
A resident with diabetes, requiring a consistent carbohydrate diet, was served regular gelatin and pudding instead of sugar free options. Both nursing and dietary staff confirmed the desserts did not meet the resident's prescribed dietary needs, and the facility's policy for diabetic diets was not followed.
Surveyors found that clear storage cups of gelatin in the kitchen refrigerator were not consistently labeled or dated according to facility policy, with several cups either unlabeled or only marked as sugar free. The Dietary Supervisor confirmed the labeling lapse, which affected a large number of residents who receive food from the kitchen.
A CNA failed to follow perineal care procedures for a resident with frequent incontinence, using a single wet towel to clean both the front and back perineal areas without rinsing or drying, contrary to facility policy. The resident required extensive assistance due to medical conditions and was at risk for pressure injuries. The CNA acknowledged not following the correct protocol during the observed care.
A CNA failed to perform hand hygiene at required intervals while providing perineal care and assisting with wound dressing changes for a resident with cancer and incontinence. The CNA used the same towel for multiple areas, did not change gloves or sanitize hands after cleaning bowel movement, and only performed hand hygiene before starting and after discarding soiled items, contrary to facility policy.
A resident with dementia and severe cognitive impairment was prescribed Seroquel for psychosis and agitation, but the facility failed to complete required monthly behavioral symptom summaries for five months. Despite physician orders and facility policy mandating ongoing monitoring and documentation, staff did not evaluate or summarize the resident's behavioral symptoms during this period, resulting in a lack of assessment for the continued need and effectiveness of the psychotropic medication.
A resident with dementia and hypertension, prescribed Seroquel for psychosis and agitation, had an episode of physical aggression documented in an SBAR form by an LVN, but the same episode was not recorded in the MAR as required. The LVN acknowledged the error, and the ADON confirmed that accurate shift documentation of behavioral episodes is expected for residents on psychotropic medications, in line with facility policy.
The facility failed to ensure call lights were accessible and promptly responded to for residents, leading to potential delays in care. A resident with a history of falls had her call light out of reach, while another resident's active call light was ignored by the DON. Additionally, a resident with reduced mobility struggled to use the standard call light, highlighting the need for adaptive devices.
The facility failed to create comprehensive care plans for two residents, one requiring oxygen therapy and the other on multiple antibiotics for a UTI. Despite physician orders, the care plans did not address these treatments, as confirmed by staff interviews and record reviews. This oversight contravenes the facility's policy on person-centered care plans.
Two residents in the facility received insulin injections without proper site rotation, contrary to professional standards and facility policy. One resident, with impaired cognition, received repeated injections in the same abdominal area over several days, while another resident, capable of understanding, experienced similar issues. A nurse confirmed the oversight, which deviated from guidelines meant to prevent skin damage.
A LTC facility failed to replace an open medication emergency kit within the required timeframe, leading to potential risks for residents. Additionally, there was a discrepancy in the controlled medication count for a resident, and a resident did not receive their routine medication, Gemtesa, due to unavailability and documentation errors. These deficiencies highlight issues in medication management and documentation practices.
A resident with schizophrenia and depression continued to receive aripiprazole despite a PMHNP's order to discontinue it due to stable symptoms. The facility's records showed the medication was administered daily, contrary to the order, and the resident's MDS indicated no behavioral symptoms justifying its use. The DON confirmed the oversight, acknowledging the risk of unnecessary medication administration.
A facility failed to maintain a medication error rate below five percent, resulting in a 24% error rate for a resident. The LVN crushed and administered medications without a physician's order, contrary to facility policy. The resident, with no documented swallowing issues, received medications inappropriately, as confirmed by the PCP and DON.
A facility failed to prevent significant medication errors by not rotating insulin injection sites for two residents and administering expired medications to two others. Insulin injections were repeatedly given in the same area, contrary to policy, and expired insulin and eye drops were administered, violating storage and labeling protocols. These actions were confirmed by staff and highlighted in the facility's policies.
A facility failed to properly label and store medications, including a Forteo pen, insulin Lantus pen, and other medications, leading to potential risks for residents. Medications were found without open date labels or pharmacy labels, and some were expired. Staff acknowledged these issues, highlighting the importance of proper labeling and disposal to ensure medication efficacy and resident safety.
The facility failed to document food temperatures on the tray line, risking food safety for 143 residents. The ADS took temperatures of various foods but did not record some, confirmed by the DS and DON. This omission violated the facility's policy and posed a risk of foodborne illness.
A facility failed to follow infection control and safety protocols, including leaving a leftover muffin in a resident's room, not labeling oxygen tubing, and neglecting hand hygiene during wound care and medication administration. These deficiencies were observed in multiple residents, increasing the risk of infection and foodborne illness.
A facility failed to maintain a resident's Living Will in the medical record, despite the resident's Advance Directive Acknowledgement Form indicating its existence. The resident, with intact cognitive skills and requiring partial assistance, had diagnoses including atrial fibrillation and heart failure. Interviews revealed that the facility did not follow its policy to obtain and maintain the Living Will, risking the resident's end-of-life treatment preferences not being honored.
A facility failed to notify a resident's representative when a medication was no longer covered by insurance, leading to a lapse in administration. Additionally, another resident's family was not informed of a MRSA diagnosis, despite the implementation of contact precautions. These deficiencies highlight communication breakdowns in notifying family members of significant changes in residents' conditions.
A facility failed to transmit a resident's MDS assessment to CMS within the required timeframe following discharge. The resident, who had a periprosthetic fracture, osteoarthritis, and type 2 diabetes, required moderate assistance for daily activities. The MDSC and DON confirmed the oversight, acknowledging the necessity of timely submission to prevent delays in care and payment.
A resident at high risk for falls had a care plan that was not updated to reflect the need for bilateral landing mats, as required by the facility's policy. Despite the resident's severe cognitive impairment and dependency on staff, only one mat was used, increasing the risk of injury. Interviews with facility staff confirmed the lack of proper assessment and implementation of the intervention.
A resident with hearing loss was unable to communicate effectively due to a malfunctioning hearing aid, which was not reported by staff as required by facility policy. The ADON confirmed that the resident's communication was impaired, potentially delaying necessary care.
A resident with cognitive impairments and specific activity preferences was not provided with outdoor activities for two months, despite the facility's policy to cater to individual preferences. The Activity Director acknowledged the oversight, which was contrary to the resident's documented preference for outdoor activities.
A resident with a stage 2 pressure ulcer did not receive continuous treatment as required. The treatment nurse failed to notify the physician before the treatment stop date, resulting in a lapse in care. The facility's policy required contacting the physician to determine if treatment should continue, which was not done, potentially worsening the ulcer.
A resident, assessed as unsafe to self-administer medications, was found with Diclofenac Gel at the bedside, brought by a family member without proper assessment or physician's order. Additionally, the resident, at high risk for falls, had only one floor mat instead of the required two, as per the care plan. The facility's policies on medication self-administration and fall prevention were not followed, leading to potential risks.
A resident with respiratory failure and hypoxia did not receive oxygen as per the physician's order. The nasal cannula was found under the resident's gown instead of being connected, despite the oxygen concentrator being on. This oversight was confirmed by an RN and acknowledged by the DON, highlighting a deficiency in providing necessary respiratory care.
A facility failed to follow its pain management protocols for a resident with cancer and gout, resulting in missed pain assessments after changes in condition and incomplete documentation of pain evaluations. The resident experienced constant pain, but the facility did not conduct required assessments or monitor pain on specific dates, as confirmed by a registered nurse.
A facility failed to document post-dialysis assessments for a resident with end-stage renal disease, omitting vital signs and access site evaluations on two occasions. This oversight, acknowledged by the ADON, could lead to undetected complications such as bleeding, contrary to the facility's care policy.
A facility failed to act on a Consultant Pharmacist's recommendation to administer Ferrous Sulfate to a resident with anemia. The Quality Assurance Nurse did not communicate the recommendation to the physician, resulting in no action being taken. This oversight placed the resident at risk for untreated anemia, as the facility's policy requires monthly medication reviews to promote positive outcomes.
A facility failed to maintain accurate EMAR for a resident prescribed Gemtesa for overactive bladder. Between February 11 and February 19, licensed nurses inconsistently documented the medication's administration, leading to inaccurate records. The resident, with a history of Alzheimer's and Parkinson's, experienced discrepancies in medication availability and charting. Interviews revealed errors by LVNs, highlighting the importance of accurate documentation per facility policy.
A facility failed to create a person-centered care plan for a resident with gastrointestinal atony, leading to a deficiency. The resident, with diagnoses of pneumonia and cerebral infarction, required maximum assistance with daily activities. Despite a physician's order for a KUB X-ray revealing an ileus and a recommendation for increased mobility, the facility did not develop a care plan to address this condition, violating their policy.
A resident with intact cognition reported being run over by another resident's wheelchair, but the incident was not reported within the required two-hour timeframe. The LPN who received the report did not immediately inform the ADM or DON, believing it was only an attempt. The facility's policy mandates prompt reporting of all abuse allegations to ensure resident safety, but the report to the SSA was delayed.
A resident with a history of stroke, atrial fibrillation, and hypertensive heart disease experienced elevated blood pressure. The facility staff failed to notify the physician immediately and did not complete a Change of Condition Form, as required by the facility's policy.
The facility staff failed to re-check and monitor a resident's elevated blood pressure after administering Cardizem LA. Despite the resident's significant medical history, there was no documentation of follow-up monitoring, placing the resident at risk for further episodes of elevated blood pressure.
Dumpster Area Not Kept Free of Spillage
Penalty
Summary
Improper disposal of garbage and refuse was identified when surveyors observed dry, black sticky substance on the grounds in front of and to the right of both dumpsters, and the left dumpster had black substance dripping from it. During interview, the Dietary Supervisor stated she could not identify the source or nature of the black stains and sticky substances. The Director of Maintenance stated the black dumpster was used for regular, non-hazardous trash, acknowledged wet black substance on the ground in the right front corner of the two black dumpsters, and stated the dumpster area should be clean and without spillage from the dumpsters. He also stated the spillage odor can be unpleasant and that spills can attract insects, cockroaches, and rats that could enter the facility and potentially cause or spread infection to residents. Facility policy for sanitation stated garbage and refuse containers are to be in good condition, without leaks, waste properly contained in the dumpster/compactors with lids covered, and garbage disposal areas free from odors and waste fats and maintained to prevent pests.
Unsafe Bedside Conditions and Missed Fall-Protection Measures
Penalty
Summary
The facility failed to provide a safe environment for a resident with a seizure history by not having padding on the upper bed rails. The resident was admitted with diagnoses including traumatic subdural hemorrhage and type 2 diabetes, and the record also showed a seizure diagnosis with an order for levetiracetam 500 mg by mouth twice daily for seizure prophylaxis. During observation, the resident was sitting up in bed and the upper bed rails were metal and unpadded. An LVN stated the bed did not have the needed padding to keep the resident safe during a potential seizure, and the DON stated staff should have applied padding to the siderails to protect the resident's head and body in the event of a seizure. The facility also left vitamin A&D ointment and an unlabeled cup containing a white paste at another resident's bedside. That resident had diagnoses including atherosclerotic heart disease, chronic pain syndrome, and anxiety disorder, and the record showed the resident could make own decisions and required substantial assistance with several activities of daily living. During observation, two open individually packaged A&D ointment packets and a half-filled unlabeled medication cup with a white paste and spoon were found on the bedside table. The LVN stated the A&D ointment and medicine cup with unknown substance should not have been at the bedside, and the DON stated the items were inappropriate and should have been disposed of after use. The facility also failed to have bilateral floor mats in place for a resident with a physician order for a low bed with bilateral landing mats when in bed. The resident had diagnoses including acute kidney failure, muscle weakness, and unspecified dementia, with a BIMS score of 2 and no capacity to make own decisions due to senile dementia. The care plan identified fall risk related to generalized weakness, multiple falls, and dementia, and included an intervention to place a floor pad next to the bed. During observation, the resident was lying in bed with no bilateral landing floor mats on either side. Staff interviews showed one CNA was unaware of the order, one LVN stated the mats should be in place if ordered, another LVN stated the order should have been discontinued because the resident had been free of falls for about 6 months, and the DON stated staff should have followed and implemented the physician order.
Medication Error and Medication Control Deficiencies
Penalty
Summary
A medication administration error occurred for one resident who was prescribed a multiple vitamin tablet orally once daily at 9 a.m. The resident’s MAR showed an order for a multiple vitamin without minerals, but during observation an LVN administered a multivitamin with minerals tablet instead. The resident was observed swallowing the multivitamin with minerals with a bottle of Boost. The resident’s admission record identified diagnoses including anemia and dysphagia. The LVN later acknowledged that the physician order was for a multivitamin not containing minerals and stated the wrong medication had been given. The LVN described the event as a medication error and stated that giving the multivitamin with minerals may not be beneficial and may cause adverse effects. The DON also stated that the resident did not receive the ordered multivitamin without minerals and confirmed that this was considered a medication error. The facility also had medication control and emergency supply issues. Two medication eKits containing controlled medications in separate medication rooms did not have accountability logs showing reconciliation at each shift change for May 2026, and staff stated these kits should be reconciled every shift. In addition, one open medication eKit in a medication cart had been opened on 4/27/2026 and was still awaiting replacement at the time of observation, despite the facility policy stating used doses should be replaced within 24 hours of opening or the next scheduled delivery, or as required by state regulation.
Medication Refrigerator Contained Food and Resident Self-Administered Ointment Was Unlabeled
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles in Medication Room Station 4 when the medication refrigerator contained resident medications together with one carton of orange juice and one carton of apple juice. During observation, LVN 3 confirmed the refrigerator should be used only for medications and stated that storing food with medications created a risk of cross contamination. The DON later stated the refrigerator was intended for medication storage only and that keeping the juice cartons with medications was not consistent with facility policy and procedures. Resident 160, who had diagnoses including atherosclerotic heart disease, chronic pain syndrome, and anxiety disorder, was documented as able to make self-understood and understand others, and the record also indicated the resident had capacity to make own decisions. During observation in the resident’s room, an unlabeled box of Neosporin was found on a tray table in front of the resident. The resident stated she applied the ointment to sores and could not specify when or how often she used it, while also stating she needed a new supply because it was almost empty. During a later observation, the resident emptied the unlabeled Neosporin tube from the box and stated she used it herself when needed. The DON stated the Neosporin should have had a label, that medications for self-administration are supposed to have the resident’s name and other pertinent information per physician orders, and that medication without a label should never be left at the bedside. The DON also stated that if medication was brought in by the resident or family, it would need to be sent home or verified and labeled through the pharmacy in accordance with the facility’s medication labeling and storage policy.
Food Storage, Equipment Sanitation, and Tray Line Temperature Monitoring Failures
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen. During an initial kitchen tour, oranges, tomatoes, and broccoli were observed stored in a container with a sticker label dated 6/1/2026, and cups filled with red liquid plus a single serving of pre-packaged prune juice were observed in reach-in refrigerator #1 with a label dated 5/3/2026, while separate cups filled with red liquid were observed in reach-in refrigerator #2 with a label dated 5/5/2026. The Dietary Supervisor stated the produce label date was incorrect and should have been 5/1/2026, and stated the prepared juices were intended for resident service and should have been labeled with their use-by date. The Dietary Supervisor also stated the juices found in refrigerator #1 had been prepared on 5/2/2026 and should have been discarded on 5/3/2026, but were still stored in the refrigerator beyond the use-by date. During a later kitchen observation, three cutting boards were observed with faded, white, scratched, and grooved surfaces along the edges. The Dietary Supervisor stated food could get trapped in these areas and lead to bacterial growth that may contaminate food prepared for residents. During tray line observation, [NAME] 1 was observed checking temperatures of multiple foods, but three foods on the tray line were not initially checked, including salad greens and egg salad, which were later checked by the Dietary Supervisor. The Breakfast/Lunch Food Temperature logs also contained blank entries, showing that some temperatures were not documented. Staff interviews showed that [NAME] 1 was responsible for hot food temperatures, Cook 2 for cold foods, and DA 1 was recording temperatures for hot foods that day, but DA 1 stated all temperatures were not recorded at the time they were taken. The DS and DON stated hot and cold food temperatures should be checked and recorded to ensure food is served within required temperature ranges.
No Designated Refrigerator for Residents’ Outside Food
Penalty
Summary
The facility failed to provide a safe storage refrigerator designated for residents’ food brought in from outside sources. During interviews, the DON stated there was no refrigerator for food brought in by families from outside the facility, and the RD stated the facility could not store outside food unless it was non-perishable. The RD further stated hot and cold foods could sit out for 2 hours and then had to be thrown out, and explained that the facility did not have a separate refrigerator because of concerns about liability, monitoring, and the work involved in labeling residents’ food. The facility policy titled, Food Brought by Family/Visitors, stated food left with the resident to consume later is to be labeled and stored so it is clearly distinguishable from facility-prepared food, while perishable foods cannot be stored in the facility and should be consumed within 2 hours. Resident 97 was admitted with acute kidney failure, had moderately impaired cognition, required supervision with eating, and was on a fortified regular texture diet. During interview, Resident 97 stated she would like to store outside food in the facility for a day or two and believed everyone would like their food stored as well. Resident 134 was admitted with hemiplegia, was cognitively intact, required setup or clean-up assistance with eating, and was on a regular diet. Resident 134 stated he would like to have a refrigerator to store food brought in from the outside. Resident 106 was re-admitted with severe protein-calorie malnutrition, was severely cognitively impaired, was independent with eating, and was on a fortified puree diet. The resident’s family member stated she wished to have food brought in from outside stored at the facility. The Administrator stated the facility told families that hot and cold foods had to be eaten within a certain time frame because the facility did not store residents’ food, and the Dietary Supervisor stated that after the Covid-19 pandemic corporate said the facility would no longer hold food for residents, although before Covid-19 the facility had a refrigerator designated for residents’ outside food.
Failure to Assess Safe Self-Administration of Bedside Medication
Penalty
Summary
The facility's interdisciplinary team failed to ensure that Resident 160's self-administration of medication was appropriate and safe by not completing a Self-Administration Safety Screen before allowing the resident to keep and use Neosporin at the bedside. Resident 160 was admitted with diagnoses including atherosclerotic heart disease, chronic pain syndrome, and anxiety disorder. The resident's record also showed the resident was able to make self understood and understand others, but required substantial to maximal assistance with multiple activities of daily living and transfers. The history and physical stated the resident had the capacity to make own decisions. During review with the DON, the physician's order for Neosporin at the bedside was confirmed, and the DON stated the resident had not been assessed for self-administration and no Self-Administration Safety Screen was found in the medical record. During observation, a box of Neosporin was seen on the resident's bed tray table. The resident stated the ointment was applied to sores and pointed to redness near the ear, but could not specify how often it was used or all of the locations where it was applied. The TAR showed licensed staff initials documenting the bedside Neosporin order across shifts.
Call lights not kept within reach for two residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents. Resident 60 was admitted and re-admitted with diagnoses including COPD, acute respiratory failure with hypoxia, and need for assistance with personal care. The MDS indicated the resident usually made herself understood and usually understood others, but had severely impaired cognitive function and required assistance with toileting hygiene, personal hygiene, showering/bathing, oral hygiene, and eating. During observation in the resident’s room, the call light was found on the floor on the left side of the bed, and a CNA stated the clip had not been used to keep it in place, causing it to fall off the bed and become out of reach. Resident 144 was admitted and re-admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, type 2 DM, and PVD. The MDS indicated the resident was able to make self understood and understand others, had moderately impaired cognition, and required assistance with toileting hygiene, lower body dressing, bathing, oral hygiene, personal hygiene, and eating. During observation and interview in the resident’s room, the call light was dangling off the upper bed rail and the resident stated he did not know where it was. A care partner stated the call light was out of the resident’s reach and should always be within reach for the resident to call for assistance. The DON stated that the call light should always be placed within reach of residents so they can request assistance as needed, and that failing to keep it accessible may delay the provision of care and services. The facility policy titled, Answering the Call Light, stated to ensure the call light is accessible to the resident while in bed, from the toilet, from the shower or bathing facility, and from the floor. Both residents had care plan interventions to ensure the call light was within reach and to encourage use for assistance as needed.
Resident Room Temperature Below Comfortable Range
Penalty
Summary
The facility failed to ensure one of four sampled resident rooms, the shared room for two residents, was maintained within a comfortable temperature range of 71 degrees Fahrenheit to 81 degrees Fahrenheit. One resident had diagnoses including a left humerus fracture, history of falling, and dementia, was not capable of making her own medical decisions, had severe cognitive impairment, and was dependent on staff for most ADLs. The other resident was admitted with acute and chronic respiratory failure and difficulty walking, was capable of making her own medical decisions, was cognitively intact, and required substantial assistance with most ADLs. During interview, the second resident and a family member stated the facility was too cold, especially at night, and extra blankets from home still did not make it comfortable. The Director of Maintenance measured the shared room at 70 degrees Fahrenheit, and a second room at 68 degrees Fahrenheit, while stating the goal was to keep resident rooms between 73 and 76 degrees Fahrenheit for comfort unless residents preferred otherwise. The DON stated the facility should be kept at a comfortable temperature to provide a homelike environment and that if it is too cold it will not be comfortable for residents. The facility policy on Homelike Environment stated residents are to be provided a safe, clean, comfortable, and homelike environment, including a comfortable and safe temperature of 71 to 81 degrees Fahrenheit.
CPR Certification Lacked Required Hands-On Training
Penalty
Summary
The facility failed to ensure that LVN 5 maintained a current CPR certification from a CPR provider whose training included a hands-on session in accordance with accepted national standards. During an employee file audit, the record for LVN 5 contained a certificate of completion for CPR training through CPR Training Provider 1. The Infection Preventionist stated the facility offers CPR training but will accept outside courses if an employee takes one. During interview, CP 1 stated she was unsure whether LVN 5's CPR training included a hands-on component. LVN 5 stated the CPR training was completed through a website recommended by a past instructor and consisted of online videos and a test based on the online content, with no in-person hands-on component. The DON stated CPR training should have a hands-on component to ensure staff know how to do CPR correctly, and that if a staff member does not know how to do CPR correctly there is a risk of harming the resident or death. Review of CPR Training Provider 1's website showed it did not offer hands-on training, and the facility's policy required CPR certification through a provider whose training includes hands-on practice and skills assessment.
Failure to Float Heels and Use Heel Protectors as Ordered
Penalty
Summary
The facility failed to ensure pressure injury care was provided consistent with professional standards of practice for a resident with bilateral heel pressure injury prevention orders. The resident was admitted with diagnoses including type 2 diabetes mellitus, falls, and dysphagia, and the MDS indicated the resident was only sometimes understood by others and required assistance with several activities of daily living. A physician’s order dated 4/26/2026 directed that bilateral heels be floated when in bed with heel protectors and/or a wedge to offload pressure. During a concurrent observation and interview, an LVN observed that only the right heel had a heel protector and neither foot was floated. During a concurrent interview and record review, the LVN reviewed the physician’s orders and stated both heels should have been floated with heel protectors to prevent further skin breakdown. The DON later stated the resident’s heels must be floated and have protectors on at all times while in bed, and that licensed nurses and CNAs work together to prevent worsening of the resident’s heel pressure injury. The facility policy on Skin and Wound Monitoring and Management stated pressure injuries are prevented by repositioning and using pressure relieving, reducing, and redistributing devices including wedges and pillows.
IV insertion site and date label were covered with tape
Penalty
Summary
The facility failed to ensure the IV insertion site and the label indicating the date of insertion were visible and not covered with white tape for one resident who was admitted with diagnoses including UTI, bacteremia, and dementia. The resident’s H&P indicated he did not have the capacity to make his own medical decisions, and his MDS showed he required substantial assistance with activities such as eating. His care plan for IV therapy complications, initiated after admission, directed staff to monitor and document signs and symptoms of infection and leaking at the IV site, and the active order summary directed staff to monitor the IV site every shift for signs and symptoms of complications. During observation, the resident was seen sitting in his wheelchair with white tape wrapped around his left AC area. When the RN examined the arm, she stated the white tape was covering the IV insertion site and that the site and insertion-date label could not be observed because they were covered. She stated she could not fully implement the order to monitor the IV site because it was not visible and complications could have been missed, and she could not verify when the IV had been inserted because the date label was covered. The DON stated the IV insertion site must be visible to monitor for complications and that nurses should not have added that much white tape; if the dressing was loose, it should have been reinforced or changed instead.
Undated Nebulizer and Tubing
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident 172 when a hand-held nebulizer and tubing were observed without a date label indicating when they were last changed. Resident 172 was admitted on 4/26/2026 with diagnoses including UTI, bacteremia, and dementia, and the H&P stated he did not have the capacity to make his own medical decisions. The MDS dated 5/3/2026 indicated he required substantial assistance for activities such as eating. His active order summary included an order for Ipratropium-Albuterol inhalation solution via nebulizer every 6 hours as needed for shortness of breath. During a concurrent observation and interview on 5/4/2026 at 8:51 a.m., Resident 172 was sitting in his wheelchair watching television, and a hand-held nebulizer was observed on top of his bedside table without a label showing the date it was last changed. RN 2 stated the nebulizer did not have a label indicating the date it was last changed and explained that oxygen tubing or a hand-held nebulizer must be labeled with the date and time it was last changed so staff would know when it was due for a change to prevent the growth of bacteria and cross contamination. The DON later stated that medical devices such as nasal cannulas, nebulizers, and tubing must be dated with the date they were changed, and that Resident 172's hand-held nebulizer should have had a label indicating the date it was last changed. The facility policy titled Oxygen Administration stated tubing must be changed every 7 days and the date and time changed must be documented.
Side Rails Installed Without Documented Informed Consent
Penalty
Summary
The facility failed to maintain an environment free from accident hazards for one resident when left and right upper quarter-length side rails were installed without documented informed consent. Resident 22 was admitted with diagnoses including acute and chronic respiratory failure, dementia, and difficulty walking. The resident’s H&Ps indicated he was not capable of making his own medical decisions, and the MDS showed severe cognitive impairment and varying levels of assistance needed with ADLs. The resident had an active order for bilateral quarter rails for increased mobility and transfers, and the care plan directed staff to provide education to the resident or representative and obtain informed consent for use of positioning bars/rails. During record review, the Positioning Bar/Rail and Informed Consent form indicated the resident was educated on the risks and benefits of the side rails, but it did not show that informed consent was obtained. The ADON stated there was no other documentation of informed consent in the side rail assessments. The DON stated the resident was not fully oriented and his family member, who was his representative, should have been notified and given education about the risks and benefits, and that informed consent should have been obtained from the family member. An observation at the bedside showed two quarter-length side rails attached and raised on the upper part of the bed.
Failure to Develop and Implement Individualized Bowel and Bladder Retraining Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans for bowel and bladder (B&B) retraining for three residents who were assessed as candidates for such programs. For Resident 2, the admission record showed diagnoses including atherosclerosis of the aorta, lumbar vertebral fracture, low back pain, and mixed incontinence. The MDS documented intact cognition, a need for moderate to maximal assistance with toileting-related ADLs, and that the resident was always incontinent of bowel and bladder. A B&B continence assessment identified the resident as a candidate for Prompted Voiding, Habit Training/Scheduled Voiding, or Bladder Retraining. However, the care plan on toileting and incontinence, while noting risk for incontinence-associated dermatitis and a goal to decrease incontinence episodes, did not specify which B&B retraining program would be used or include individualized approaches or interventions describing how the program would be carried out. Resident 3’s admission and assessment information showed diagnoses including diabetes mellitus and reduced mobility, intact cognitive skills for daily decision making, and a need for maximal assistance or dependence for toileting hygiene, showering, lower body dressing, and toilet transfers. The MDS indicated the resident was always incontinent of both bladder and bowel, and the B&B assessment identified the resident as a candidate for Prompted Voiding, Habit Training/Scheduled Voiding, or Bladder Retraining. The care plan reports, initiated and later revised, documented that the resident was incontinent of bowel and bladder and set goals to decrease urinary and bowel incontinence episodes. Despite this, the care plans did not identify the specific type of B&B retraining program to be implemented and did not include individualized approaches or interventions outlining how the retraining program would be implemented. Resident 4’s records showed admission with diagnoses including atherosclerosis of the aorta, left femur fracture, and presence of a left artificial hip joint. The MDS documented intact cognition, a need for maximal assistance with toileting hygiene and showering, dependence for lower body dressing and toilet transfers, and that the resident was always incontinent of bowel and bladder. A B&B assessment again identified candidacy for Prompted Voiding, Habit Training/Scheduled Voiding, or Bladder Retraining. The care plan, which noted bowel and bladder incontinence and a goal to decrease incontinence episodes during the retraining period, did not specify which B&B retraining program would be used and did not include specific, individualized approaches or interventions. During interviews and record reviews, the MDS nurse and the ADON acknowledged that individualized, person-centered care plans addressing B&B retraining programs, including the type of program and specific interventions, had not been developed and implemented for these three residents, despite facility policy requiring comprehensive, person-centered care plans based on ongoing assessments.
Failure to Implement and Document Individualized Bowel/Bladder Retraining Programs
Penalty
Summary
The deficiency involves the facility’s failure to implement its own policies and procedures for assessment and management of urinary and fecal incontinence for three cognitively intact residents who were always incontinent of bowel and bladder. Resident 2 was admitted with diagnoses including atherosclerosis of the aorta, lumbar vertebral fracture, low back pain, and mixed urinary incontinence. An MDS showed intact cognitive skills and a need for moderate to maximal assistance with toileting-related ADLs, with total dependence for toilet transfers, and documented that the resident was always incontinent of bowel and bladder. A bowel/bladder continence assessment identified the resident as a candidate for a Prompted Voiding Program, Habit Training/Scheduled Voiding, or Bladder Retraining, but did not specify which program would be used or any individualized interventions. The care plan for toileting and incontinence risk noted a goal to decrease incontinence episodes but likewise did not identify a specific retraining program or individualized approaches. Resident 3, originally admitted with diabetes mellitus and reduced mobility, also had an MDS indicating intact cognitive skills, maximal assistance needs for toileting hygiene and showering, dependence for lower body dressing and toilet transfer, and that the resident was always incontinent of bowel and bladder. A bowel/bladder assessment again identified candidacy for Prompted Voiding, Habit Training/Scheduled Voiding, or Bladder Retraining. However, the care plan, which documented that the resident was always incontinent of bowel with a goal to decrease bowel incontinence episodes, did not specify which bowel/bladder retraining program would be implemented or outline individualized interventions or approaches for carrying out such a program. Resident 4 was admitted with atherosclerosis of the aorta, a left femur fracture, and a left artificial hip joint. The MDS documented intact cognitive skills, maximal assistance needs for toileting hygiene and showering, dependence for lower body dressing and toilet transfer, and that the resident was always incontinent of bowel and bladder. The bowel/bladder assessment identified the resident as a candidate for Prompted Voiding, Habit Training/Scheduled Voiding, or Bladder Retraining, and the care plan included a goal to decrease incontinence episodes during a retraining period. Despite this, the care plan did not specify which retraining program would be used or any individualized interventions. Interviews with the MDS nurse and the ADON confirmed there was no documentation that any bowel/bladder retraining program had been implemented for these residents, nor any documentation that the residents had been offered, agreed to, or declined participation, despite facility policies requiring appropriate continence services, scheduled toileting or prompted voiding as indicated, and documentation of toileting trials and programs in the medical record.
Failure to Administer Insulin as Prescribed
Penalty
Summary
A deficiency occurred when a resident with a history of type 2 diabetes mellitus, cerebral infarction, and long-term insulin use did not receive their prescribed insulin glargine as ordered by the physician. The resident, who had severe cognitive impairment and required significant assistance with daily activities, had a physician's order for insulin glargine to be administered at bedtime if their blood sugar was not less than 100 mg/dL. On the date in question, the resident's blood sugar was recorded at 100 mg/dL, which was within the parameters for administration, but the insulin was not given. Interviews with nursing staff revealed that the omission was due to the nurse overlooking the parameters of the order and not reading it in its entirety. Both the registered nurse and the assistant director of nursing confirmed that the medication should have been administered according to the physician's order and facility policy, which requires medications to be given as prescribed. The facility's policy also emphasizes the importance of administering medications in a safe and timely manner, in accordance with prescriber orders.
Diabetic Resident Served Non-Compliant Desserts
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus, who was on a consistent carbohydrate/no added salt diet and required substantial assistance with daily activities, was served regular gelatin and regular pudding instead of sugar free alternatives. The resident's care plan specifically indicated the need for dietary restrictions and compliance with a nutritional regimen to manage hyperglycemia. During lunch service, the gelatin provided was unlabeled, and the pudding cup was marked with an 'R', which staff confirmed indicated regular pudding. Both a Licensed Vocational Nurse and the Registered Dietician verified that the items served were not sugar free and did not meet the dietary requirements for a diabetic resident. The facility's policy on consistent carbohydrate diets, which is intended for residents with diabetes, was not followed in this instance. The Registered Dietician stated that the resident should have received sugar free gelatin and pudding in accordance with their prescribed diet. The failure to provide the appropriate diet was observed during meal service and confirmed through interviews and record review, demonstrating noncompliance with the resident's care plan and facility dietary policies.
Failure to Label and Date Prepared Gelatin in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to follow proper food handling practices by not ensuring that clear storage cups of gelatin were labeled and dated according to the facility's policy. During an inspection of the kitchen refrigerator, open food items not in their original packaging were found in clear storage cups, with several cups either unlabeled or only marked with 'SF' for sugar free. The Dietary Supervisor confirmed that 35 cups had no label and 11 were labeled 'SF', and explained that the person preparing the gelatin is responsible for labeling. The facility's policy requires that any food item removed from its original container must be labeled with the specific name of the food and the date it was opened or prepared. This deficiency had the potential to affect 142 out of 148 residents who receive food from the facility's kitchen. The Dietary Supervisor acknowledged the importance of accurate labeling for resident safety and to ensure the correct identification of food items. A review of the facility's policy confirmed the requirement for labeling and dating prepared foods, which was not followed in this instance.
Failure to Follow Perineal Care Protocol for Incontinent Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the facility's perineal care policy and procedures while providing care to a resident who was frequently incontinent of bladder and occasionally incontinent of bowel. The CNA used a single large wet towel to clean both the front perineal area and the anal/buttocks area, folding and reusing the same towel throughout the process. The CNA did not rinse or dry the resident's perineal area during the care. This method did not align with the facility's policy, which requires the use of separate towels with soap and water for different areas, as well as thorough rinsing and drying. The resident involved had a history of malignant neoplasm of the right breast, secondary malignant neoplasm of the brain, and was at risk for developing pressure ulcers or injuries. The resident was dependent on staff for toileting hygiene and required significant assistance with lower body dressing and toilet transfers. The incident was observed by surveyors, and during interviews, the CNA acknowledged awareness of the correct procedures but admitted to not following them during the observed care. The Director of Nursing confirmed the CNA's knowledge of the proper protocol.
Failure to Perform Proper Hand Hygiene During Perineal Care
Penalty
Summary
Certified Nursing Assistant 3 (CNA 3) failed to follow proper infection control practices while providing perineal care to a resident who was dependent on staff for toileting hygiene, had a history of malignant neoplasm of the breast with secondary brain involvement, and was at risk for pressure ulcers. During the observed care, CNA 3 used the same towel to clean both the front perineal area and the anal/buttocks area, refolding it to use different sections, and did not change gloves or perform hand hygiene (HH) after cleaning the resident's bowel movement. CNA 3 then assisted a treatment nurse with wound dressing changes and subsequently changed the resident's brief and clothing, only performing HH after discarding the soiled items. When questioned, CNA 3 acknowledged that she was supposed to wash her hands and change gloves after cleaning the perineal area and before touching the resident's body, new brief, or clothing, but admitted to performing HH only twice during the entire process. The Infection Preventionist confirmed that CNA 3 did not perform HH at the appropriate times as required by facility policy, specifically after contact with body fluids and before moving from a soiled to a clean body site on the same resident. Facility policies reviewed indicated that hand hygiene is the primary means to prevent the spread of healthcare-associated infections and outlined specific requirements for HH during resident care.
Failure to Monitor and Summarize Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications by not evaluating and summarizing the resident's behavioral symptoms for a period of five months while the resident was prescribed Seroquel for psychosis and agitation associated with dementia. The resident, who had severe cognitive impairment and required maximal assistance with daily activities, had a physician's order for Seroquel to be administered at bedtime for psychosis as evidenced by hallucinations or agitation leading to aggression. The order also required monitoring of episodes of psychosis, agitation, aggression, and hallucinations every shift. Despite these requirements, the facility did not complete the required monthly Psychotropic Drug Behavior Monitoring (PDBM) summaries from January through May. The last available PDBM summary was from December of the previous year. Both the Assistant Director of Nursing and the Director of Nursing confirmed that no behavioral symptom summaries were completed during this period and that the facility relied on these summaries to evaluate the effectiveness and necessity of the psychotropic medication. The facility's policy required adequate monitoring and documentation for the use of psychotropic medications, which was not followed in this case.
Failure to Accurately Document Behavioral Episodes in MAR
Penalty
Summary
The facility failed to ensure complete and accurate documentation in the Medication Administration Record (MAR) for a resident with dementia and hypertension. The resident, who had severely impaired cognitive skills and required maximal assistance with daily activities, was prescribed Seroquel for psychosis and agitation. Physician orders required monitoring and documentation of episodes of psychosis, agitation, or aggression every shift. On a specific date, a Licensed Vocational Nurse (LVN) completed an SBAR Communication Form indicating an episode of physical aggression but documented in the MAR that there were no such episodes during the same shift. During interviews and record reviews, the LVN acknowledged the documentation error, stating that the MAR should have reflected the episode of aggression. The Assistant Director of Nursing (ADON) confirmed that licensed nurses are expected to accurately document behavioral episodes in the MAR for residents on psychotropic medications, as per facility policy. The facility's policy emphasized that medical records should be objective, complete, and accurate to facilitate communication among the care team.
Failure to Ensure Call Light Accessibility and Prompt Response
Penalty
Summary
The facility failed to ensure that residents were provided with a call light within reach, which is essential for signaling the need for assistance. Resident 34, who was admitted with conditions such as atherosclerotic heart disease, muscle weakness, and a history of falls, was observed with her call light under the mattress and not within reach. This was confirmed by a Care Partner and a Registered Nurse, both of whom acknowledged the importance of having the call light accessible to prevent delays in care. The facility's policy mandates that call lights be within reach to allow residents to call for help. Resident 134, who had a history of falls and required moderate assistance for daily activities, was observed with an active call light that was not addressed by the Director of Nursing (DON) who walked by the room twice without entering. The DON admitted that the call light should have been addressed immediately to prevent delays in care. The facility's policy requires that call lights be answered as soon as possible, but no later than five minutes. Resident 395, who was admitted with sepsis, major depressive disorder, and reduced mobility, was found unable to reach the call light due to weakness in her hands and arms. The call light was under her pillow, and she demonstrated difficulty using it. A Licensed Vocational Nurse confirmed the resident's inability to use the regular call light and mentioned the availability of adaptive devices. The facility's policy states that alternative communication means should be provided for residents unable to use the standard call system.
Failure to Develop Comprehensive Care Plans for Oxygen and Antibiotic Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to potential inadequate care. Resident 345, who was admitted with chronic obstructive pulmonary disease and acute respiratory failure, required intermittent oxygen therapy. Despite physician orders specifying oxygen administration and equipment maintenance, the facility did not create a care plan addressing the resident's oxygen use. This oversight was confirmed during interviews with a registered nurse and the Director of Nursing, who acknowledged the absence of a care plan with specific goals and interventions for oxygen use. Similarly, the facility did not develop a care plan for Resident 27's antibiotic use, despite multiple physician orders for antibiotics to treat a urinary tract infection. The resident, who had diagnoses including acute respiratory failure and type 2 diabetes, was prescribed several antibiotics, but the care plans did not reflect this treatment. The Minimum Data Set Coordinator and the Director of Nursing confirmed the lack of a care plan addressing the antibiotic administration, which is crucial for providing specific interventions related to these medications. The facility's policy and procedure on comprehensive person-centered care plans require the development of care plans based on thorough assessments and clinical decision-making. However, the facility did not adhere to these guidelines, resulting in the failure to create necessary care plans for the residents' oxygen and antibiotic use. This deficiency was identified through interviews and record reviews, highlighting the facility's non-compliance with its own policies.
Failure to Rotate Insulin Injection Sites
Penalty
Summary
The facility failed to ensure that insulin injections were administered in accordance with professional standards of practice by not rotating the injection sites for two residents. Resident 76, who was admitted with diagnoses including type 2 diabetes mellitus, neuropathy, and major depressive disorder, received insulin injections repeatedly in the same area of the abdomen over several days in February 2025. This practice was contrary to the facility's policy and the manufacturer's guidelines, which require rotation of injection sites to prevent skin damage and medication errors. Similarly, Resident 111, who was admitted with type 2 diabetes mellitus and major depressive disorder, also received insulin injections in the same area of the abdomen multiple times in December 2024. Despite having the capacity to understand and make decisions, the resident's insulin administration did not adhere to the recommended practice of site rotation. The facility's policy and the medication insert instructions both emphasize the importance of rotating injection sites to avoid adverse effects such as lipodystrophy and localized cutaneous amyloidosis. During interviews and record reviews, a registered nurse acknowledged the failure to rotate injection sites for both residents, highlighting a deviation from the facility's procedures and professional standards. The facility's policies on adverse consequences and medication errors, as well as insulin administration, clearly outline the necessity of site rotation to prevent skin tissue damage and ensure proper medication administration.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to replace an open medication emergency kit within the required 72-hour timeframe. During an observation, it was noted that the kit, labeled B002, was opened on February 13, 2025, and had not been replaced by February 24, 2025. This oversight was acknowledged by RN 1, who stated that the kit should have been replaced within 24 hours, as per facility policy, to ensure emergency medications are available when needed. Additionally, there was a discrepancy in the controlled medication count for a resident, where one dose of pregabalin was missing from the medication bubble pack compared to the Controlled Drug Record accountability log. LVN 4 admitted to administering the medication but failing to document it, which is against the facility's policy. This lack of documentation could lead to medication errors and potential harm to the resident. The facility also failed to provide a resident with their routine medication, Gemtesa, for over a week due to unavailability. Despite the medication being marked as administered in the EMAR, it was confirmed by LVNs that the medication was not available during that period. This error in documentation and follow-up resulted in the resident not receiving their prescribed medication, which could have worsened their condition.
Failure to Discontinue Unnecessary Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically concerning the administration of an antipsychotic medication, aripiprazole. The resident, who had a diagnosis of schizophrenia and depression, was prescribed aripiprazole 5 mg to be administered as 2.5 mg daily. Despite a Psychiatric Mental Health Nurse Practitioner's (PMHNP) order on January 24, 2025, to discontinue the medication due to the stability of the resident's psychosis symptoms, the medication continued to be administered daily until February 18, 2025. The Minimum Data Set (MDS) for the resident, dated February 4, 2025, indicated that the resident was moderately impaired in cognitive skills for daily decision-making and had no mood or behavioral symptoms such as screaming. The MDS also noted that a Gradual Dose Reduction (GDR) was attempted on February 2, 2025, but there was no documentation from a physician indicating that the GDR was clinically contraindicated. Despite the PMHNP's note on February 7, 2025, indicating no apparent distress after discontinuing the medication, the facility's Medication Administration Record (MAR) showed that the resident continued to receive the medication daily. During a review and interview with the Director of Nursing (DON) on February 26, 2025, it was confirmed that the facility failed to discontinue the medication as per the PMHNP's orders. The DON acknowledged that the resident did not exhibit any documented behaviors that would justify the continued use of the medication, aligning with the PMHNP's orders to attempt a GDR by discontinuing aripiprazole. This oversight placed the resident at risk of receiving unnecessary psychotropic medications, which could result in adverse consequences and side effects, negatively impacting the resident's health and well-being.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to ensure that the medication error rate was less than five percent, resulting in a 24% error rate for one resident during medication administration. Six out of 25 medication opportunities were administered incorrectly to a resident, as the medications were crushed and mixed with applesauce without a physician's order to do so. The Licensed Vocational Nurse (LVN) involved acknowledged the error, stating that medications should only be crushed with a physician's order, and admitted to not contacting the physician to obtain such an order. The resident involved, who was admitted with diagnoses including dementia, atherosclerosis, and hypertension, did not have any documented difficulty swallowing. The primary care physician confirmed that there were no orders to crush the medications and was unaware of any swallowing issues. The facility's policy requires medications to be administered according to prescriber orders and specifies that medications should only be crushed when appropriate and consistent with physician orders. The Director of Nursing confirmed that the LVN failed to follow the facility's policy by crushing the medications without an order.
Significant Medication Errors in Insulin Administration and Expired Medications
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the improper administration of insulin and expired medications. Two residents, both diagnosed with type 2 diabetes mellitus, were subjected to repeated insulin injections in the same area without site rotation, contrary to the facility's policy and professional standards. This practice was observed in the medication administration records of both residents, with injections consistently administered in the left upper quadrant of the abdomen for one resident and the left lower quadrant for the other. The failure to rotate injection sites was acknowledged by a registered nurse during a review, who confirmed that this constituted a medication error. Additionally, the facility administered expired medications to two residents. One resident received a dose of expired insulin Fiasp, while another received two doses of expired latanoprost eye drops. The expired medications were found in a medication cart, improperly stored and labeled, and were administered by licensed vocational nurses. The facility's policies and procedures, as well as manufacturer instructions, were not followed, leading to the administration of these expired medications. The Director of Nursing confirmed that the facility failed to dispose of expired medications as per policy, which could result in decreased potency and effectiveness of the medications. The facility's policies on medication administration and storage were not adhered to, resulting in significant medication errors. The policies clearly outlined the need for rotating injection sites and discarding expired medications, yet these were not followed, leading to the deficiencies observed. The report highlights the facility's failure to comply with professional standards and its own procedures, resulting in potential harm to the residents involved.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and store medications in accordance with manufacturers' requirements and facility policies, leading to potential risks for residents. During an observation in Medication Room Station 2, a Forteo pen for a resident was found without an open date label, contrary to the manufacturer's instructions to discard the pen 28 days after first use. This oversight was acknowledged by RN 1, who confirmed the importance of labeling to prevent the use of ineffective medication. In Medication Room Station 1, an insulin Lantus pen was discovered without a pharmacy label, making it unclear which resident it belonged to. LVN 3 confirmed that facility policy requires all medications to be labeled with the resident's name to prevent accidental administration to the wrong resident. The lack of labeling posed a risk of medication errors and potential transmission of blood-borne pathogens. Further deficiencies were noted in Medication Cart 2 Station 4, where several medications were either improperly labeled or expired. A fluticasone and salmeterol inhalation powder device for a resident was not labeled with an open date, making it impossible to determine its expiration. Additionally, an expired Fiasp Flextouch pen and latanoprost eye drop bottle were found, both of which had been used beyond their recommended dates. LVN 5 acknowledged these issues, emphasizing the importance of proper labeling and timely disposal to ensure medication efficacy and resident safety.
Failure to Document Food Temperatures on Tray Line
Penalty
Summary
The facility failed to ensure proper documentation of food temperatures on the tray line, which is crucial for maintaining food safety standards. During an observation, the Assistant Dietary Supervisor (ADS) was noted to have taken temperatures of various food items, including soup, beef, vegetables, and others, but failed to record the temperatures of fish, cottage cheese, diced chicken, beans, and mashed potatoes. This omission was confirmed during an interview and record review with the ADS, who acknowledged that these temperatures should have been documented to ensure food safety and prevent potential foodborne illnesses. The Dietary Supervisor (DS) and the Director of Nursing (DON) both emphasized the importance of maintaining a complete Food Temperature Log to ensure that all food served is within the safe temperature range. The facility's policy, last reviewed in January 2025, mandates that food temperatures be taken and recorded before meal service. The failure to document these temperatures posed a risk to the 143 medically compromised residents who rely on the facility's kitchen for their meals, as it could lead to harmful bacteria growth and cross-contamination, potentially resulting in foodborne illnesses.
Infection Control and Safety Protocol Failures
Penalty
Summary
The facility failed to ensure proper food safety protocols were followed for a resident, identified as Resident 96, who was found with a leftover blueberry muffin from the previous day on their bedside table. The muffin was uncovered and exposed to air, which could lead to contamination and potential foodborne illness if consumed. The Dietary Supervisor confirmed that leftover food should be discarded after two hours to prevent such risks, but the muffin remained in the resident's room beyond this time frame. Another deficiency was observed in the facility's failure to adhere to their oxygen administration policy for Resident 345. The resident's oxygen tubing was not labeled with the date and time of the last change, as required by the facility's procedures. This oversight was acknowledged by both a Certified Nursing Assistant and a Licensed Vocational Nurse, who confirmed that the tubing should be changed weekly and labeled accordingly to prevent infection risks. The facility also did not comply with hand hygiene protocols during wound care for Resident 32. Treatment Nurse 2 failed to use alcohol-based hand rub after removing gloves, which is a critical step in preventing the spread of infection. Additionally, a Licensed Vocational Nurse did not perform hand hygiene before preparing and administering medication to another resident, further increasing the risk of infection spread. These lapses in infection control practices were acknowledged by the facility's Infection Preventionist and Director of Nursing, who emphasized the importance of following established hand hygiene procedures.
Failure to Maintain Resident's Living Will in Medical Record
Penalty
Summary
The facility failed to implement its policy and procedure for Advance Directives for one of the sampled residents by not obtaining and maintaining a copy of the resident's Living Will in the medical record. The resident, who was originally admitted in 2017 and readmitted later, had diagnoses including weakness, atrial fibrillation, and heart failure. The Minimum Data Set indicated that the resident's cognitive skills for daily decision-making were intact, and the resident required partial assistance for certain activities. The Advance Directive Acknowledgement Form, signed by the resident's Responsible Party, indicated that the resident had executed a Living Will and provided it to the facility. Interviews with the Social Worker and the Director of Social Services revealed that the facility did not have a copy of the resident's Living Will in the medical chart, despite the acknowledgment form indicating its existence. The facility's policy required that copies of Advance Directives be obtained and maintained in the resident's medical record in a readily retrievable location. The failure to have the Living Will in the medical chart meant that the resident's end-of-life treatment preferences might not be honored, as the staff would not be aware of the resident's wishes.
Failure to Notify Resident Representatives of Medication and Condition Changes
Penalty
Summary
The facility failed to notify the resident's representative when a resident's medication, Gemtesa, was no longer covered by insurance and before it ran out. This affected Resident 112, who had been admitted with diagnoses including Alzheimer's Disease, Parkinson's Disease, and major depressive disorder. The medication was crucial for managing urinary incontinence, and its discontinuation without notification had the potential to negatively impact the resident's care. The Licensed Vocational Nurse (LVN) documented the medication as not available and awaiting refill, but the family was not informed until several days later, leading to a lapse in medication administration. In another instance, the facility failed to notify a resident's representative of a change in condition when Resident 27 was diagnosed with Methicillin-Resistant Staphylococcus aureus (MRSA). Despite the diagnosis and the implementation of contact precautions, the family member was only informed of a urinary tract infection and a room change, not the MRSA diagnosis. This lack of communication was confirmed through interviews with staff, including Licensed Vocational Nurses and the Social Worker, who acknowledged the oversight in notifying the family about the MRSA diagnosis. The facility's policy and procedure require prompt notification of changes in a resident's medical condition to the resident, their physician, and their representative. However, in both cases, this policy was not followed, leading to deficiencies in communication and potential negative impacts on the residents' care. The failure to notify the family members about significant changes in the residents' conditions highlights a breakdown in the facility's communication processes.
Failure to Timely Transmit MDS Assessment
Penalty
Summary
The facility failed to ensure the timely transmission of the Minimum Data Set (MDS) assessment to the Centers for Medicare and Medicaid Services (CMS) system for a resident, identified as Resident 30. The resident was admitted with diagnoses including a periprosthetic fracture around an internal prosthetic left knee, osteoarthritis, and type 2 diabetes. The resident required moderate assistance for all activities of daily living and had mildly impaired cognition. Despite these needs, the MDS assessment, which is required to be completed and submitted within 14 days of discharge, was not completed or submitted to CMS following the resident's discharge. Interviews with the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON) confirmed the oversight. The MDSC acknowledged the requirement to complete the MDS assessment upon discharge and admitted that the assessment for Resident 30 was neither completed nor submitted. The DON reiterated the necessity of submitting the discharge assessment within the stipulated timeframe to avoid delays in care and payment. The facility's failure to adhere to these requirements was identified as a deficiency, with the potential to delay services for the resident.
Failure to Revise Care Plan for Fall Risk Resident
Penalty
Summary
The facility failed to revise a resident's care plan to accurately reflect the use of floor or landing mats for a resident at high risk for falls. The resident, who was severely impaired in cognition and dependent on staff for dressing and footwear, had a history of falls and was identified as high risk for falls in a Fall Risk Evaluation. Despite this, the care plan initially included only one landing mat, contrary to the intervention added to the care plan which indicated the need for mats on both sides of the bed. This discrepancy was observed during an interview and record review, where it was noted that only one mat was being used, and there was no current order for any landing mat. The deficiency was further highlighted during interviews with facility staff, including a CNA, LVN, ADON, and DON, who confirmed the lack of proper assessment and implementation of the intervention for bilateral landing mats. The facility's policy on fall prevention and comprehensive person-centered care plans emphasized the need for thorough assessment and appropriate interventions, which were not followed in this case. The failure to update the care plan and implement the necessary interventions increased the risk of injury for the resident in the event of a fall.
Failure to Maintain Resident's Hearing Aid Functionality
Penalty
Summary
The facility failed to ensure that a resident's hearing aid was functioning properly, which impacted the resident's ability to communicate effectively. The resident, who was admitted with diagnoses including muscle weakness and hearing loss, was observed stating that her hearing aid was broken and that she could not hear. Despite the Minimum Data Set (MDS) indicating that the resident could hear adequately with a hearing aid, the resident repeatedly reported the malfunction to staff, including the Assistant Director of Nursing (ADON) and a Certified Nurse Assistant (CNA). The ADON acknowledged that the resident's ability to communicate needs to caregivers was compromised due to the malfunctioning hearing aid. The facility's policy required staff to notify a supervisor if a hearing aid was damaged, but there was no record of such a report being made to the Social Services Department. This oversight had the potential to delay necessary care, treatment, or services for the resident.
Failure to Provide Resident with Preferred Outdoor Activities
Penalty
Summary
The facility failed to provide activities according to the preferences of a resident, identified as Resident 98, which resulted in a deficiency. Resident 98 was admitted with diagnoses including hepatomegaly and benign prostatic hyperplasia. The Minimum Data Set (MDS) assessment indicated that the resident had severely impaired cognitive skills and required maximal assistance for daily activities. Importantly, the MDS noted that it was important for the resident to go outside for fresh air when the weather was good. Despite this preference, the Activity Director (AD) confirmed during an interview and record review that Resident 98 had not participated in outdoor activities for the past two months. The facility's policy on Activity Programs, which was last reviewed in January 2025, stated that activities should be designed to meet the interests and well-being of each resident based on their preferences. The AD acknowledged that outdoor activities were beneficial for the resident's well-being and should have been provided, indicating a failure to adhere to the resident's activity preferences.
Failure to Continue Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide care consistent with professional standards for a resident with a stage 2 pressure ulcer in the sacral region. The resident, who had severe cognitive impairment and required maximal assistance for daily activities, was admitted with this condition. A physician's order was in place to treat the ulcer with normal saline, zinc oxide, and a dry dressing for 21 days. However, the treatment was discontinued on the 21st day without notifying the physician, even though the ulcer had not fully healed. The treatment nurse did not inform the physician before the treatment stop date, resulting in a lapse in care from the 22nd to the 30th day. The treatment was only resumed on the 31st day and continued for six days. The facility's policy required the nurse to contact the physician one day before the treatment stop date to determine if the treatment should continue, which was not done. This oversight had the potential to worsen the pressure ulcer and lead to infection.
Failure to Prevent Medication Mismanagement and Inadequate Fall Prevention
Penalty
Summary
The facility failed to ensure that a resident, who was assessed as unsafe to self-administer medications, was not left unattended with Diclofenac Gel 1% at the bedside. The resident, who was severely impaired in cognition and dependent on staff for daily activities, was observed with the medication on the bedside table. The Licensed Vocational Nurse (LVN) and Treatment Nurse (TN) were unable to locate the medication in the medication cart, and it was revealed that the resident's family member had brought the medication to the facility. The facility's policy required an assessment and physician's order for self-administration, which was not completed for this resident. Additionally, the facility failed to provide adequate fall prevention measures for a resident at high risk for falls. The resident's care plan indicated the need for floor mats on both sides of the bed, but only one mat was observed in use. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the resident required two landing mats due to a previous fall and the potential to fall on either side when attempting to get out of bed. The facility's policies on self-administration of medications and fall prevention were not followed, leading to potential risks for the resident. The interdisciplinary team did not assess the resident's ability to self-administer medication, and the necessary fall prevention interventions were not fully implemented, as evidenced by the observations and interviews conducted during the survey.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care to Resident 136, who was admitted with diagnoses including respiratory failure with hypoxia, heart failure, and parkinsonism. The physician's order required oxygen administration at two liters per minute via nasal cannula as needed to maintain oxygen saturation above 90%. However, during an observation, it was found that the nasal cannula was not connected to the resident but was instead under the resident's gown, while the oxygen concentrator was on. This oversight was confirmed by RN 2, who acknowledged the need for oxygen administration to maintain the resident's oxygen saturation levels. The Director of Nursing confirmed that oxygen should be administered according to the physician's order to prevent the worsening of the resident's respiratory condition. The facility's policy on oxygen administration emphasized the importance of securely anchoring the tubing and ensuring the proper placement of the oxygen device on the resident. The failure to adhere to these guidelines and the physician's order resulted in a deficiency in providing necessary respiratory care to Resident 136, potentially impacting the resident's respiratory well-being.
Failure to Follow Pain Management Protocols
Penalty
Summary
The facility failed to adhere to its policy and procedure for pain assessment and management for a resident, identified as Resident 38, who was admitted with diagnoses including secondary malignant neoplasm of bone and peritoneum, and gout. The resident's Minimum Data Set (MDS) indicated that they experienced almost constant pain over a five-day period and were dependent on staff for various activities of daily living. Despite this, the facility did not conduct pain assessments following changes in the resident's condition on two occasions, specifically on 12/8/2024 and 2/13/2025, when the resident experienced new or worsening pain. Additionally, the facility did not thoroughly complete the Pain Risk Evaluation form for Resident 38 on 12/30/2024. The form failed to include the names of both scheduled and PRN medications used for the resident, which is a requirement for a complete assessment. Furthermore, the facility did not monitor the resident for the presence of pain on two specific dates, 2/7/2025 and 2/23/2025, during the evening shift, as indicated by the absence of entries in the Medication Administration Record (MAR). During an interview, a registered nurse confirmed these deficiencies, acknowledging that the licensed staff did not develop and complete pain risk evaluations after the resident's changes in condition and failed to document pain monitoring as required. The facility's policy mandates comprehensive pain assessments upon admission, quarterly, and whenever there is a significant change in condition, which was not followed in this case.
Failure to Document Post-Dialysis Assessments
Penalty
Summary
The facility failed to complete the Hemodialysis Communication Record for a resident requiring dialysis services, specifically omitting post-dialysis assessments of the access site and vital signs. This deficiency was identified during a review of the resident's records and an interview with the Assistant Director of Nursing (ADON). The resident, who was admitted with end-stage renal disease and impaired cognitive skills, had an order for dialysis treatment three times a week. However, on two specific dates, the required post-dialysis assessments were not documented, which is a critical step in monitoring for potential complications such as redness, swelling, drainage, or prolonged bleeding at the access site. The ADON acknowledged the importance of these assessments, noting that failure to perform them could lead to undetected complications, potentially resulting in negative outcomes like bleeding and hemorrhage. The facility's policy on the care of residents with end-stage renal disease, last reviewed in January 2025, mandates adherence to recognized standards of care, including post-dialysis assessments. The omission of these assessments represents a deviation from the facility's established procedures and places the resident at risk for serious health issues.
Failure to Act on Pharmacist's Recommendation for Anemia Treatment
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist's recommendation for a Medication Regimen Review (MRR) was discussed with the physician and acted upon for a resident diagnosed with anemia. The Consultant Pharmacist recommended administering Ferrous Sulfate, an iron supplement, to stimulate erythropoiesis. However, the Quality Assurance Nurse (QAN), responsible for communicating these recommendations to the physician, did not discuss this recommendation with the physician, as there was no documentation indicating that the recommendation was acted upon or that the physician disagreed with it. The resident, who was originally admitted in 2020 and readmitted later, had a diagnosis of anemia, among other conditions. The resident required maximal assistance with daily activities and had the ability to communicate and understand others. The facility's policy requires the Consultant Pharmacist to review each resident's medication regimen monthly to promote positive outcomes and minimize risks. The failure to communicate the pharmacist's recommendation placed the resident at increased risk for untreated anemia, which could lead to complications such as fatigue and weakness.
Inaccurate EMAR Documentation for Resident's Medication
Penalty
Summary
The facility failed to maintain accurate electronic medical administration records (EMAR) for a resident, identified as Resident 112, who was prescribed Gemtesa for overactive bladder. The deficiency occurred between February 11, 2025, and February 19, 2025, when licensed nurses did not accurately chart the administration of the medication. The EMAR showed discrepancies where some nurses marked the medication as administered, while others indicated it was on hold due to unavailability. This resulted in inaccurate documentation in the resident's medical record. Resident 112, who was admitted to the facility on June 15, 2023, had a medical history that included Alzheimer's Disease, Parkinson's Disease, major depressive disorder, and a history of falling. The resident's physician had noted improvement in bladder spasms and urination when on Gemtesa, and the medication was to be continued. However, the EMAR entries showed inconsistencies, with some nurses marking the medication as given when it was not available, and others indicating it was on hold due to awaiting a refill from the pharmacy. Interviews with the involved licensed vocational nurses (LVNs) revealed that the medication was not available on certain days, yet it was mistakenly documented as administered. LVN 8 and LVN 9 admitted to errors in charting, acknowledging the importance of accurate documentation. LVN 4 confirmed the medication was unavailable on specific dates and had informed the resident's family about the issue. The facility's policy and procedure on charting and documentation emphasized the need for objective, complete, and accurate records, which was not adhered to in this case.
Failure to Develop Comprehensive Care Plan for Resident with Ileus
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with gastrointestinal atony, which is a condition where the stomach cannot contract normally, leading to delayed movement of food. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, who was originally admitted in October 2023 and readmitted in December 2023, had diagnoses including pneumonia and cerebral infarction. The Minimum Data Set (MDS) indicated that the resident had intact cognition but required maximum assistance with various activities of daily living. On December 14, 2023, a physician's order was made for an immediate KUB X-ray to assess the resident's abdominal pain, which revealed an ileus. The physician was informed of the results and recommended increased mobility for the resident. However, during a review conducted in July 2024, it was found that the facility had not developed a comprehensive care plan to address the resident's ileus condition. This oversight was contrary to the facility's policy, which mandates the creation of a comprehensive, person-centered care plan with measurable objectives and timetables for each resident.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to adhere to its policy and procedures for reporting a reasonable suspicion of a crime, specifically in the case of a physical abuse allegation involving two residents. Resident 1, who had intact cognition, reported to the Social Service Director and Director of Nursing that Resident 2 ran over him with her wheelchair. This incident was reported to have occurred on 6/8/2024, but the initial report was not made within the required two-hour timeframe. Licensed Vocational Nurse 1, who was informed of the incident by Resident 1, did not report it to the Administrator or Director of Nursing immediately, as she believed it was only an attempt and not an actual incident of abuse. The facility's policy requires that all abuse allegations, whether attempted or actual, be reported within two hours to ensure resident safety. However, the allegation was not reported to the State Survey Agency until 6/10/2024, which was beyond the required timeframe. The facility's policy on abuse, neglect, exploitation, or misappropriation, last revised in 9/2022, mandates that all reports of resident abuse be reported to local, state, and federal agencies and thoroughly investigated. The failure to report the incident promptly had the potential to delay necessary actions to protect the residents.
Failure to Notify Physician of Elevated Blood Pressure
Penalty
Summary
The facility staff failed to notify the physician immediately of a change in condition for a resident who experienced an episode of elevated blood pressure. The resident, admitted with diagnoses including cerebral infarction, atrial fibrillation, and hypertensive heart disease with heart failure, had a blood pressure reading of 193/93. Despite this significant elevation, there was no documented evidence that the physician was notified or that a Change of Condition Form was completed. The Director of Nursing confirmed that the licensed nurse should have notified the physician and completed the necessary documentation upon identifying the elevated blood pressure. The resident's Medication Administration Record indicated that the elevated blood pressure was recorded, and the prescribed medication, Cardizem LA, was administered. However, the lack of immediate notification to the physician and the absence of a Change of Condition Form were identified as deficiencies. The facility's policy requires prompt notification of the physician and the resident's representative in the event of a change in medical condition, which was not adhered to in this instance.
Failure to Monitor Elevated Blood Pressure
Penalty
Summary
The facility staff failed to re-check and monitor a change in condition for one resident who experienced an episode of elevated blood pressure. The resident, admitted with diagnoses including cerebral infarction, atrial fibrillation, and hypertensive heart disease with heart failure, had a blood pressure reading of 193/93. Despite administering Cardizem LA as prescribed, there was no documented evidence that the resident's blood pressure was re-checked and monitored 30 minutes to an hour after administration to determine the medication's effectiveness. During an interview and record review, the Director of Nursing confirmed the absence of documentation indicating that the resident's blood pressure was monitored following the administration of the medication. The facility's policy on hypertension management emphasizes the importance of monitoring and documenting blood pressure trends and isolated elevations. The failure to follow this protocol placed the resident at risk for further episodes of elevated blood pressure due to the lack of immediate medical treatment and intervention.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 3,032 citations issued within 25 miles in the last 12 months — including the 26 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Canoga Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Hills Health And Rehabilitation Center | 0.4 mi | ★★★★★ | 17 | 1 |
| West Valley Post Acute | 0.6 mi | ★★★★★ | 57 | 0 |
| Topanga Terrace | 0.8 mi | ★★★★★ | 16 | 0 |
| Holiday Manor Care Center | 1.9 mi | ★★★★★ | 21 | 0 |
| Woodland Care Center | 2.9 mi | ★★★★★ | 19 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Canyon Oaks Nursing And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.